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Get FL Informed Consent for Psychotherapeutic Medication

Cribed for a child in the Medicaid program without the express and informed consent of the child's parent or legal guardian. The physician shall document the consent in the child's medical record and provide the pharmacy with a signed attestation of this documentation with the prescription. Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY) / Recipient’s Full Name / Prescriber’s Full Name Prescriber License # (ME, OS, AR, PA) Prescriber Phone Number Prescriber Fax Number - - Psy.

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